Skip to main content

Advertisement

SpringerLink
Log in

Thoracic Anesthesia: A Review of Current Topics and Debates

  • Thoracic Anesthesia (T Schilling, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Thoracic anesthesia is a continually evolving field due to the development of new surgical and anesthetic technologies. Advances in lung isolation techniques, ventilation strategies, and postoperative pain management have improved patient outcomes. Airway management continues to progress as different devices provide advantages and disadvantages for lung isolation, surgical visualization, and access to the operative lung. Optimal ventilation strategies are moving toward lung protection, where oxygenation and ventilation are maintained with lower, more physiologic lung volumes with judicious use of alveolar recruitment, positive end-expiratory pressure, and lower FiO2. Neuraxial and regional anesthetics are the mainstays of postoperative analgesia, with adjuvants having roles in the acute period, but chronic post-thoracotomy pain remains challenging to treat. The role of perioperative inflammation has grown in importance, and volatile anesthetics have protective effects at the cellular and molecular levels, however the debate between the use of volatiles versus a total intravenous anesthetic technique continues.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Fischer GW, Cohen E. An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol. 2010;23(1):7–11.

    Article  PubMed  Google Scholar 

  2. Cohen E. Management of one-lung ventilation. Anesthesiol Clin N Am. 2001;19(3):475–495, vi.

    Article  CAS  Google Scholar 

  3. Miller RD. Miller’s anesthesia, vol. 2. 8th ed. Elsevier Health Sciences: Benjamin; 2014.

    Google Scholar 

  4. Ma M, Slinger P. Lung isolation techniques. In: Hines R, editor. UpToDate. Waltham: UpToDate; 2014. Accessed 15 Dec 2015.

  5. Neustein SM. The use of bronchial blockers for providing one-lung ventilation. J Cardiothorac Vasc Anesth. 2009;23(6):860–8.

    Article  PubMed  Google Scholar 

  6. Campos JH. Effects of oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg. 1997;85(3):583–6.

    Article  CAS  PubMed  Google Scholar 

  7. •• Clayton-Smith A, et al. A comparison of the efficacy and adverse effects of double-lumen endobronchial tubes and bronchial blockers in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2015;29(4):955–66. Important meta-analysis that evaluates pros and cons of double-lumen endobronchial tubes and bronchial blockers.

  8. Campos JH, Reasoner DK, Moyers JR. Comparison of a modified double-lumen endotracheal tube with a single-lumen tube with enclosed bronchial blocker. Anesth Analg. 1996;83(6):1268–72.

    Article  CAS  PubMed  Google Scholar 

  9. Campos JH, Massa FC. Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with right-sided enclosed bronchial blocker. Anesth Analg. 1998;86(4):696–700.

    Article  CAS  PubMed  Google Scholar 

  10. Grocott HP, et al. Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker. J Cardiothorac Vasc Anesth. 2003;17(6):725–7.

    Article  PubMed  Google Scholar 

  11. Mourisse J, et al. Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology. 2013;118(3):550–61.

    Article  CAS  PubMed  Google Scholar 

  12. Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker. Anesth Analg. 2003;96(1):283–9 (Table of contents).

    Article  PubMed  Google Scholar 

  13. Dumans-Nizard V, et al. A comparison of the deflecting-tip bronchial blocker with a wire-guided blocker or left-sided double-lumen tube. J Cardiothorac Vasc Anesth. 2009;23(4):501–5.

    Article  PubMed  Google Scholar 

  14. Ruetzler K, et al. Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. Br J Anaesth. 2011;106(6):896–902.

    Article  CAS  PubMed  Google Scholar 

  15. Narayanaswamy M, et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg. 2009;108(4):1097–101.

    Article  CAS  PubMed  Google Scholar 

  16. Bauer C, et al. Bronchial blocker compared to double-lumen tube for one-lung ventilation during thoracoscopy. Acta Anaesthesiol Scand. 2001;45(2):250–4.

    CAS  PubMed  Google Scholar 

  17. Campos JH, Hallam EA, Ueda K. Lung isolation in the morbidly obese patient: a comparison of a left-sided double-lumen tracheal tube with the Arndt(R) wire-guided blocker. Br J Anaesth. 2012;109(4):630–5.

    Article  CAS  PubMed  Google Scholar 

  18. Cohen E. Back to blockers?: the continued search for the ideal endobronchial blocker. Anesthesiology. 2013;118(3):490–3.

    Article  PubMed  Google Scholar 

  19. Campos JH, et al. Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker. Anesthesiology. 2006;104(2):261–6 (Discussion 5A).

    Article  PubMed  Google Scholar 

  20. Knoll H, et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology. 2006;105(3):471–7.

    Article  PubMed  Google Scholar 

  21. Zhong T, et al. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesth Intensive Care. 2009;37(3):441–6.

    CAS  PubMed  Google Scholar 

  22. Stout DM, et al. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology. 1987;67(3):419–21.

    Article  CAS  PubMed  Google Scholar 

  23. Yuceyar L, et al. Bronchial rupture with a left-sided polyvinylchloride double-lumen tube. Acta Anaesthesiol Scand. 2003;47(5):622–5.

    Article  CAS  PubMed  Google Scholar 

  24. Gilbert TB, Goodsell CW, Krasna MJ. Bronchial rupture by a double-lumen endobronchial tube during staging thoracoscopy. Anesth Analg. 1999;88(6):1252–3.

    Article  CAS  PubMed  Google Scholar 

  25. Hannallah M, Gomes M. Bronchial rupture associated with the use of a double-lumen tube in a small adult. Anesthesiology. 1989;71(3):457–9.

    Article  CAS  PubMed  Google Scholar 

  26. Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact CardioVasc Thorac Surg. 2014;18(5):626–35.

    Article  PubMed  Google Scholar 

  27. Fitzmaurice BG, Brodsky JB. Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth. 1999;13(3):322–9.

    Article  CAS  PubMed  Google Scholar 

  28. Benumof J. Anesthesia for thoracic surgery, vol. xiv. 2nd ed. Philadelphia: W.B. Saunders; 1995. p. 799.

    Google Scholar 

  29. DellaRocca G, Coccia C. Ventilatory management of one-lung ventilation. Minerva Anestesiol. 2011;77(5):534–6.

    CAS  Google Scholar 

  30. Della Rocca G, Coccia C. Acute lung injury in thoracic surgery. Curr Opin Anaesthesiol. 2013;26(1):40–6.

    Article  PubMed  Google Scholar 

  31. Tenney SM, Remmers JE. Comparative quantitative morphology of the mammalian lung: diffusing area. Nature. 1963;197:54–6.

    Article  CAS  PubMed  Google Scholar 

  32. Kozian A, et al. One-lung ventilation induces hyperperfusion and alveolar damage in the ventilated lung: an experimental study. Br J Anaesth. 2008;100(4):549–59.

    Article  CAS  PubMed  Google Scholar 

  33. Jung JD, et al. Effects of a preemptive alveolar recruitment strategy on arterial oxygenation during one-lung ventilation with different tidal volumes in patients with normal pulmonary function test. Korean J Anesthesiol. 2014;67(2):96–102.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lin WQ, et al. Effects of the lung protective ventilatory strategy on proinflammatory cytokine release during one-lung ventilation. Ai Zheng. 2008;27(8):870–3.

    CAS  PubMed  Google Scholar 

  35. • Maslow AD, et al. A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection. J Thorac Cardiovasc Surg. 2013;146(1):38–44. Important study with contradictory findings of better outcomes with large tidal volume ventilation over protective ventilation strategies.

  36. Schultz MJ, et al. What tidal volumes should be used in patients without acute lung injury? Anesthesiology. 2007;106(6):1226–31.

    Article  PubMed  Google Scholar 

  37. Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin. 2008;26(2):241–272, v.

    Article  PubMed  Google Scholar 

  38. Grichnik KP, Shaw A. Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation: clinical application. Curr Opin Anaesthesiol. 2009;22(1):23–30.

    Article  PubMed  Google Scholar 

  39. Senturk M. New concepts of the management of one-lung ventilation. Curr Opin Anaesthesiol. 2006;19(1):1–4.

    Article  PubMed  Google Scholar 

  40. •• Lohser J, Slinger P. Lung injury after one-lung ventilation: a review of the pathophysiologic mechanisms affecting the ventilated and the collapsed lung. Anesth Analg. 2015;121(2):302–18. Comprehensive review of cellular and molecular mechanisms of lung injury, and how that translates into practice for thoracic anesthesia, OLV and critical care.

  41. Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Semin Cardiothorac Vasc Anesth. 2008;12(2):97–108.

    Article  PubMed  Google Scholar 

  42. Duggan M, Kavanagh BP. Atelectasis in the perioperative patient. Curr Opin Anaesthesiol. 2007;20(1):37–42.

    Article  PubMed  Google Scholar 

  43. Jordan S, et al. The pathogenesis of lung injury following pulmonary resection. Eur Respir J. 2000;15(4):790–9.

    Article  CAS  PubMed  Google Scholar 

  44. Her C, Mandy S. Acute respiratory distress syndrome of the contralateral lung after reexpansion pulmonary edema of a collapsed lung. J Clin Anesth. 2004;16(4):244–50.

    Article  PubMed  Google Scholar 

  45. Cheng YJ, et al. Oxidative stress during 1-lung ventilation. J Thorac Cardiovasc Surg. 2006;132(3):513–8.

    Article  PubMed  Google Scholar 

  46. Misthos P, et al. The degree of oxidative stress is associated with major adverse effects after lung resection: a prospective study. Eur J Cardiothorac Surg. 2006;29(4):591–5.

    Article  PubMed  Google Scholar 

  47. Senturk M, et al. A comparison of the effects of 50 % oxygen combined with CPAP to the non-ventilated lung vs. 100 % oxygen on oxygenation during one-lung ventilation. Anasthesiol Intensivmed Notfallmed Schmerzther. 2004;39(6):360–4.

    Article  CAS  PubMed  Google Scholar 

  48. Yoon SZ, Lee YH, Bahk JH. A simple method to apply continuous positive airway pressure during the use of a Univent tube. Anesth Analg. 2006;103(4):1042–3.

    Article  PubMed  Google Scholar 

  49. McGlade DP, Slinger PD. The elective combined use of a double lumen tube and endobronchial blocker to provide selective lobar isolation for lung resection following contralateral lobectomy. Anesthesiology. 2003;99(4):1021–2.

    Article  PubMed  Google Scholar 

  50. Kim YD, et al. The effects of incremental continuous positive airway pressure on arterial oxygenation and pulmonary shunt during one-lung ventilation. Korean J Anesthesiol. 2012;62(3):256–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Ferrando C, et al. Setting individualized positive end-expiratory pressure level with a positive end-expiratory pressure decrement trial after a recruitment maneuver improves oxygenation and lung mechanics during one-lung ventilation. Anesth Analg. 2014;118(3):657–65.

    Article  PubMed  Google Scholar 

  52. Unzueta C, et al. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2012;108(3):517–24.

    Article  CAS  PubMed  Google Scholar 

  53. Tusman G, et al. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg. 2004;98(6):1604–9 (Table of contents).

    Article  PubMed  Google Scholar 

  54. Tusman G, et al. Alveolar recruitment strategy increases arterial oxygenation during one-lung ventilation. Ann Thorac Surg. 2002;73(4):1204–9.

    Article  PubMed  Google Scholar 

  55. •• Rodriguez-Aldrete D, et al. Trends and new evidence in the management of acute and chronic post-thoracotomy pain: an overview of the literature from 2005 to 2015. J Cardiothorac Vasc Anesth. 2015. doi:https://doi.org/10.1053/j.jvca.2015.07.029. Review of major trends, recent trials, as well as negative findings and therapies that have fallen out of favor.

  56. Searle RD, et al. Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period? Interact CardioVasc Thorac Surg. 2009;9(6):999–1002.

    Article  PubMed  Google Scholar 

  57. Joseph C, et al. Is there any benefit to adding intravenous ketamine to patient-controlled epidural analgesia after thoracic surgery? A randomized double-blind study. Eur J Cardiothorac Surg. 2012;42(4):e58–65.

    Article  PubMed  Google Scholar 

  58. Fiorelli A, et al. Is pre-emptive administration of ketamine a significant adjunction to intravenous morphine analgesia for controlling postoperative pain? A randomized, double-blind, placebo-controlled clinical trial. Interact CardioVasc Thorac Surg. 2015;21(3):284–90.

    Article  PubMed  Google Scholar 

  59. Mauck M, Van De Ven T, Shaw AD. Epigenetics of chronic pain after thoracic surgery. Curr Opin Anaesthesiol. 2014;27(1):1–5.

    Article  PubMed  Google Scholar 

  60. Wildgaard K, Iversen M, Kehlet H. Chronic pain after lung transplantation: a nationwide study. Clin J Pain. 2010;26(3):217–22.

    Article  PubMed  Google Scholar 

  61. Qutub H, et al. Effect of tidal volume on extravascular lung water content during one-lung ventilation for video-assisted thoracoscopic surgery: a randomised, controlled trial. Eur J Anaesthesiol. 2014;31(9):466–73.

    Article  PubMed  Google Scholar 

  62. Weyker PD, et al. Lung ischemia reperfusion injury: a bench-to-bedside review. Semin Cardiothorac Vasc Anesth. 2013;17(1):28–43.

    Article  PubMed  Google Scholar 

  63. Schilling T, et al. Effects of propofol and desflurane anaesthesia on the alveolar inflammatory response to one-lung ventilation. Br J Anaesth. 2007;99(3):368–75.

    Article  CAS  PubMed  Google Scholar 

  64. Schilling T, et al. Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients. Anesthesiology. 2011;115(1):65–74.

    Article  CAS  PubMed  Google Scholar 

  65. Annecke T, et al. Ischemia-reperfusion-induced unmeasured anion generation and glycocalyx shedding: sevoflurane versus propofol anesthesia. J Investig Surg. 2012;25(3):162–8.

    Article  Google Scholar 

  66. Liu R, Ishibe Y, Ueda M. Isoflurane-sevoflurane adminstration before ischemia attenuates ischemia-reperfusion-induced injury in isolated rat lungs. Anesthesiology. 2000;92(3):833–40.

    Article  CAS  PubMed  Google Scholar 

  67. Chappell D, et al. Sevoflurane reduces leukocyte and platelet adhesion after ischemia-reperfusion by protecting the endothelial glycocalyx. Anesthesiology. 2011;115(3):483–91.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY, 10029, USA

    Nicolette Schlichting, Kenneth Flax, Adam Levine, Samuel DeMaria Jr. & Andrew Goldberg

Authors
  1. Nicolette Schlichting
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kenneth Flax
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Adam Levine
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Samuel DeMaria Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andrew Goldberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicolette Schlichting.

Ethics declarations

Conflict of Interest

Nicolette Schlichting, Kenneth Flax, Adam Levine, Samuel DeMaria, Jr., and Andrew Goldberg declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Thoracic Anesthesia.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schlichting, N., Flax, K., Levine, A. et al. Thoracic Anesthesia: A Review of Current Topics and Debates. Curr Anesthesiol Rep 6, 142–149 (2016). https://doi.org/10.1007/s40140-016-0159-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40140-016-0159-4

Keywords

Search

Navigation